Tag: Leadership

Nursing and the NHS – wtf is going on?

I cannot take credit for this, it is Roy Lilley, and although I was about to write about it,  I thought, nah, Roy has done it better: 

 

Talk to the DH and they will tell you there are more nurses than there are daffodils smiling in the spring sunshine.

 

An extra 2,400 hospital nurses have been hired since Francis and over 3,300 more nurses working on wards since May 2010.  The bit that is missing is; ‘more’ doesn’t mean ‘enough’ and enough doesn’t mean enough of the ‘right sort’.

 

The RCN says; The NHS has lost nearly 4,000 senior nursing posts since 2010.  The ‘missing’ nurses include ward sisters, community matrons and specialist nurses.  They’ve gone because they cost more; drop them and you save loadsamoney… quicker.

 

According to the latest data, November 2013; the NHS was short of 1,199 full time equivalent registered nurses compared with April 2010.  The RCN says; ‘… hidden within wider nursing workforce cuts is a significant loss and devaluation of skills and experience’… just under 4,000 FTE nursing staff working in senior positions.  Band 7 and 8 have been disproportionately targeted for workforce cuts.  It looks like nursing is being de-skilled. (Must look graph).

 

If the evidence of my in-box is to be believed nursing is not just being de-skilled, it is being denuded.  Time and time again I hear stories of nurse patient ratios of 9,10,11,12,even 18 and often quickly beefed up for the benefit of the CQC.

 

“Let each person tell the truth from their own experience.”  Florence Nightingale.

 

Funnily enough, I am writing this on a plane where the cabin-crew to passenger ratio is a matter of law.  I see no reason why the nurse to patient ratio shouldn’t be a matter of law.

 

The Chief Nurse doesn’t agree.  She’s faffing-about with her half-dozen C’s and ignores the risk that one nurse looking after a dozen or more vulnerable patients is a risk to the Six C’s.  She speaks, unthinking, with her master’s voice…  I hope she’s ready to explain the inevitable.. the next Mid-Staffs.

 

“The very first requirement in a hospital is that it should do the sick no harm.”  Flo Nightingale again.

 

There’s a wilful blindness to what’s going on; on the wards and at the ‘high-end’ of nursing; nurse specialists.  If the RCN is right (and this H&SCIC FoI confirms) it is a madness that their numbers are reducing.

 

Nurse Clinical Specialists are highly skilled and there is overwhelming evidence that better skilled nurses are better for patients, and reduce admissions, re-admissions and waiting times, free-up consultant’s, improve access to care, educate and share knowledge with other health and social care professionals and support patients in the community.

 

“Were there none who were discontented with what they have, the world would never reach anything better.”   

Fabulous Flo again.

 

Yup, I’m discontent Flo!  There are only 2 types of post-reg’ training programmes; Specialist Community Public Health Nurses and a Specialist Practice Qualification and for all practical purposes, degree entry-level.  We know they work (chronic heart failure for example and in Stoma nursing) so the default position should be; all patients, with long term conditions, should have access to a specialist nurse… but here we go again… there are not enough of them.

 

A new, free web-resource for Specialist Nurses caught my eye; help with job plans, annual reports and service summaries and I particularly liked the ‘Speaking up for my Service’ section.  I hope they and their managers do. 

 

“How little can be done under the spirit of fear.” More Flo truth-to-power-talk.

 

Nursing is the Swiss Army knife of the NHS; versatile, multi-purpose, portable, one-stop.  Nurses build, work and fix services, flex them and extend their reach and cover.  But, we patronise them and squabble over their numbers. 

 

“Let whoever is in charge keep this simple question in her head (not, how can I always do this right thing myself, but) how can I provide for this right thing to be always done?” Yes, Flo again… in full flow!

 

It looks to me very like nursing is in a muddle, confused, a jumble.  No one seems to have a clue what is ‘the right thing’, the right numbers or the right training.  Nursing, the biggest group in the NHS workforce, lacks direction… leadership.  Buried in directorates, managed by administrators shoved around by everyone’s agenda.   A Chief Nursing Officer (Carbuncle) and a Director of Nursing (DH), all chiefs but what about the Indians.

 

Events, technology, finance, balance sheets, bed-sheets, need and resources pull nursing in different directions.  The profession needs to stop, catch its breath and think about its voice, role and purpose.

I wonder what Flo would say? 

Government, managerialism, leadership and poor care in the NHS

Today the government responds to the Francis Reports into the care failings between 2005-2009 at Mid Staffordshire NHS Trust. What can we expect?

 

I suspect that there will be a good deal of initiatives and new regulatory effort but little in the way of actual practical relevance.

 

In March 2013 the government published its initial response Patients First and Foremost in which David Cameron apologised to the families involved through parliament acknowledging systemic failures. It is to these systemic failures we must look to find some answers, but I suspect that my definition of a systemic failure may not be the same as Cameron’s. First lets consider where we are so far.

 

Jeremy Hunt’s foreword in March focused on creating a culture of safety, compassion and learning that is based on cooperation and openness. He identified four key groups who are essential in providing this culture:

 

  • Patients, service users, families and friends.
  • Frontline staff.
  • Leadership teams – Trust boards.
  • External structures: commissioners, regulators, professional bodies, local scrutiny bodies and Government.

 

The government’s response was, through the CQC, to appoint a new chief Inspector of Hospitals. Secondly, making hospital performance more transparent through a system of ratings. Then, something called a ‘single failure regime’. There would also be a Chief Inspector of Social Care. In addition the government would ‘foster a climate of openness’. How it would do that when it has no control at all over NHS organisations seems moot.

 

That was 8 months ago and so we cannot expect too much to change in a group of organisations that make up the NHS brand, a brand that is now a complex system of public and private provision distinct in organisational form from each other and from social care provision. What remains of the complex system is the underpinning Health and Social Care Act 2012.

 

Many of the 12 points in this March response are hard to critique, for example who does not want ‘Respect and Dignity?’ However there is a little nugget, point 8:

 

“We will work together to minimise bureaucracy, enabling time to care and time to lead, freeing up the expertise of NHS staff and the values and professionalism that called them to serve”.

 

This goes to the heart of the process of care, but there are no short cuts to doing this. Minimising bureaucracy requires leadership to address certain managerialist cultures. Prior to Mid Staffs, Leadership was seen as a key aspect of NHS culture changes. However, Leadership operates in certain organisational cultures and that rests mainly with management and can be strangled by a managerialist culture putting organisations into a catch 22: we need leadership to change cultures but we need culture change to allow leadership. However, it is bureaucratic management chasing non care oriented targets in order to maintain or gain Foundation Trust status which have distorted the care process and hampered frontline staff’s ability to deliver. This operates in wider socio-political context of the devaluing of care in that we accept the need for care but will not provide financial and social structures to allow it to flourish. Instead we have individualised care, leaving it mainly to families and women who are often provide it for free or for low pay.

 

Of the four groups identified above by Hunt, it is the leadership teams, especially hospital management and their Boards, which carry the most responsibility for care in NHS Trusts. Patients can exercise their voices, frontline staff can advocate or try to exercise clinical leadership, external groups can respond to failures often only after the event and were largely ineffectual as they may continue to be. Roy Lilley suggested that weighing a pig does not make it fatter – you have to build in quality from the outset, inspection is a post hoc activity. Trust Boards however set the tone and provide the resources and thus have the primary responsibility for the provision of good quality hospital care.  The Secretary of State for health has now abdicated that responsibility in an increasingly market driven health care system.

 

John Robinson, age 20, died in 2006 as a result of a ruptured spleen after a mountain bike accident. He was discharged from Mid Staffs Accident and Emergency department and died less than 24 hour later. A second inquest is being conducted. Caution must therefore be exercised in making any conclusions about the quality of care John received and whether it was in fact deficient. Claims regarding negligent care require certain conditions to be met and this has not been established in this case.

 

John’s parents claim that he was examined by a junior doctor, and that a consultant was not available. They suggested that if a more senior doctor had examined John then the chance of a ruptured spleen might have been considered. The junior doctor may have been incompetent, or she/he may have been acting within the limits of his competence, we do not know. The point however is that staffing of accident and emergency, and the training and development of staff who could spot this condition, are ultimately the responsibility of the Trust Board. Professional staff have a duty to make known their concerns regarding staffing and the competence of the team they work with, but they need the confidence to act on their concerns and the recognition by management that the exercise of clinical leadership involves challenging structures of support for clinical practice.

 

Therefore, professional staff have to be able to exercise clinical leadership safe in the knowledge that issues will be listened to and acted upon. However, managerial leadership may militate against this because their aims and objectives may blind them to real clinical needs. This was a criticism of Mid Staffs management.  In John’s case, if it was the poor decision making of an inexperienced junior doctor that was a major contributor to his death, we do not know if clinical leadership was exercised to address any issues of the training and support for junior doctors.

 

John Edmonstone (2008) suggested that clinical leadership is distinct from managerial leadership and is often ignored or not addressed by those considering leadership in the NHS. In addition he describes a disconnected hierarchy operating in health care organisations: a clinical hierarchy and a managerial hierarchy. This disconnect results in differing objectives, visions and ways of working. This is reflected by Robert Francis (2013 p3) who argued that the failings at Mid Staffs was primarily caused by:

 

“a serious failure on the part of a provider Trust Board. It did not listen sufficiently to its patients and staff or ensure the correction of deficiencies brought to the Trust’s attention. Above all, it failed to tackle an insidious negative culture involving a tolerance of poor standards and a disengagement from managerial and leadership responsibilities. This failure was in part the consequence of allowing a focus on reaching national access targets, achieving financial balance and seeking foundation trust status to be at the cost of delivering acceptable standards of care”.

 

Prior to this Hewison and Griffith, in 2004 argued, “too much emphasis on leadership without an equal concern for transforming the organisations (nurses) work in may result in leadership being added to the list of transient management fads”. Hewison in 2011 went on to argue that the focus on leadership as a solution to organisational ills remains in the NHS. This is rooted in assumptions that leadership, changing cultures and producing effective leaders will result in improvements in management and organisations. Hutchinson and Jackson suggested in 2012 that discussions around leadership often fail to address the issues of power, politics, dominance and resistance in organisational cultures. Both pre date Francis comments about the nature of Trust management at Mid Staffs.

 

Faugier and Woolnough (2003) provided some evidence of what organisations feel like to work in. and thus illustrate how management cultures can distort care practices. They describes three types of organisation:

 

  1. The Machine
  2. The Choir
  3. The Living organisation.

 

In their research 45% of respondents stated that their organisation felt like a machine in which leadership is generally driven by senior management to establish order and control. Strategic decisions are made through a formal planning process and change is planned and programmatic. Employees feel like a ‘cog in a wheel’. Faugier and Woolnough concluded that there was serious work to do to ensure clinical staff feel engaged and empowered. They argued that too many staff felt like cogs with high levels of disengagement and disillusionment and that that the implications for patient care were obvious. This was written in 2003, before Mid Staffs made the headlines. One can’t help but think that the antecedents for poor quality care were already established and were being written about for some time.

 

Questions remain: Will the government be able to do anything about how individual Trusts are run and financed? Will the frontline be properly staffed and supported; will they feel free to express concern about poor quality care?

 

Is clinical leadership any better supported, and will staff feel empowered and engaged? Will today’s government response address any of the fundamental issues?

 

 

Issues to address to address in this regard:

 

  • In a public sector organisation, clinical leaders cannot easily affect, or redefine public policy or legislation set by politicians and so they operate within the conditions set by others. Since the Health and Social Care Act Government has released the reins of control and conditions to NHS organisations and can no longer provide or dictate such issues as minimum staffing levels without enacting new legislation.

 

  • Nursing culture may inhibit clinical leadership development; issues of gender and medical power may continue to inhibit strong nursing leadership within Trusts and in clinical commissioning groups.  Has nursing got the respect of the public, politicians, policy makers and other professional groups to allow the to exercise strong leadership?

 

  • The focus on developing the person, their competencies and their traits, which are often based on male assumptions about what leadership looks like, may be in conflict with the exercise of leadership that focuses on relationships (shared leadership) within complex organisations.

 

  • The ratio of professional nursing staff to non-professional staff requiring training, supervision and regulation by clinical leaders is wrong. Not enough nurses, too many support staff.

 

  • Health care organisations may be risk averse and heavily regulated which counters leadership development that encourages risk and creativity and the challenging of the status quo.

 

  • Inspection and regulation are post hoc activities: are the CQC, Monitor and the Professional Bodies fit for purpose in terms of preventing poor quality care?

Liderazgo y Gestion en Enfermeria – Leadership and Management in Nursing

Liderazgo y Gestion en Enfermeria – Leadership and Management in Nursing

Motivating our nurses – give them freedom.

What gets you up in the morning?

 An old myth about nursing is that is a vocation, a calling based on the desire to help and care for each other. Currently nurses are being criticised for being too educated to care, that they have lost their compassion. I don’t think these things are true. Nurses come to work for a variety of reasons, chief among them of course is paid employment. However, pay itself is not the issue either. Managers and governments need to address more fundamental issues if they want nurses in the NHS to fulfil their mission to provide high quality complex care.

 The first thing to do is to dump old ways of thinking regarding motivation. The theory that if you reward good performance then you will get more if it and the converse that punishment of poor performance reduces it, is flawed. Daniel Pink (2009) reviewed the science and based on a good deal of research in both private sector and public sector organisations, criticises the carrot and stick approach.

First the pay issue, the carrot and stick method works when the task is mechanical in nature needing little or no thought. Then rewards for good performance works. Tasks requiring more than rudimentary cognition are different. The globally replicated research indicates that staff who were extremely well remunerated actually performed poorly which might explain why the global finance sector crashed. High pay does not lead to high performance. Pay has to be set, though, to remove it from the table as an issue, so there is a baseline to be achieved where staff no longer worry about their salary. Beyond that level there are there are three other factors at work: Autonomy, Mastery and Purpose.

We need Autonomy to perform well and to be creative.  Second we like Mastery. It appears that we like to get better at things, we like to practice to master our skills and finally we need Purpose (or vision) over and above the profit motive. If profit (or cost cutting) is the only goal things go pear shaped. Successful organisations want to make a difference and they develop a transcendental purpose.

The lesson for the NHS is clear. Calls for more nursing leadership to address poor care will fail unless nurses are given or allowed to develop these three things: Autonomy, Mastery and Purpose…that is what will get the nurse leaders of tomorrow really making a difference. Are our organisations up to the task of setting staff free or will they not take the risk and do more of the same? Bureaucracy, managerialism and petty fogging quality processes will kill this initiative. Identify your key members of staff and then give them autonomy to be creative and to master their skills and knowledge, ‘sell’ to them a higher purpose, let them develop their own purpose, and if you don’t know what that is you have work to do. Hands up those of you who can clearly articulate that these three things are your daily experience?

Pink, D.  Drive. (2009) The surprising Truth about what motivates us. Canongate. Edinburgh.

leadership for the future

This paper is for spanish nurses on a leadership course but has general application:

“Considerable evidence suggests that neocolonialism, in the form of economic globalization as it has evolved since the 1980s, contributes significantly to the poverty and immense global burden of disease experienced by peoples of the developing world, as well as to escalating environmental degradation of alarming proportions. Nursing’s fundamental responsibilities to promote health, prevent disease, and alleviate suffering call for the expression of caring for humanity and environment through political activism at local, national, and international levels to bring about reforms of the current global economic order”. (Falk-Rafael 2006)

 

The theories and issues so far covered in this module are focused on the individual (micro) and organisational (meso) level of analysis. Nurses are asked to examine their personal resources and the culture of the clinical setting and the hospital environment in which they work. The immediate focus is on patient outcomes: their safety, their recovery, their dignity and their comfort. Many of the policy drivers for critical care rightly ask us all to consider the patient’s journey, to see the issues from their perspectives as well as from our own.

 

You have been invited to consider whether transformational leadership is a style fit for clinical practice, you have been invited to consider how interpersonal and interprofessional relationships affect your work, you have been invited to consider how we add value in a public sector organisation, you have been invited to consider applying CQI as a process in your work.  

 

But you have not been invited to take the next step: The macro analysis.

 

A macro analysis asks you to see beyond the individual, the clinical unit and the hospital. It asks you to consider wider socio-political issues that impinge on public health and well being. Critical care rightly focuses on the seriously ill individual and the skills and competencies developed for nurses reflect that. However, Nursing is an ethical endeavour, your exercise of leadership reflects your ethical positions. The decisions you don’t take may be as important as the decisions you do.  The world view you ascribe to helps to create the world you live in. You have an opportunity for just a moment to raise your eyes above the bedside and think about your vision for the future.

 

A good deal of discussion in leadership theory is about vision, that leadership is a role, it is a process and can be exercised by anyone.  Being a ‘leader’ is a post holder (chosen, elected , appointed), but a formal post may or may not exercise leadership. So I wish to ask, what are you leading for, for you are all potential leaders regardless of the formal title or post you hold. What is your vision? What are your ethics? What do you care about?

 

Sarah Parkin (2010) argues that much of leadership education does not clearly see the impending crises of unsustainable economic, business and political practice, has failed to see the wider picture and has failed to ask what is leadership for?

 

We know we live in a messy world (Peccie 1982, Morrall 2009). The financial crisis that started in 2008 continues prompting the indignados movement.  Spain has a 46.2% under 25 unemployment rate where young educated people argue:

 

“juventud sin futero, sin casa, sin curro, sin pension, sin meido.” (The Economist 2011).

 

We know that economic inequality has direct health effects (Marmot 2010, Wilkinson and Pickett 2009). We know what the under 5 mortality rate in many countries is still far above the stated target of the Millennium Development Goals (MDG 4). The WHO (2008) supports the ‘social determinants of health’ approach which links social, political and environment issues with human health. Climate change is the biggest threat to public health and security in this century (Costello et al 2009, BMA 2008, 2011, Goodman and Richardson 2009, Goodman 2011).

 

These issues, Parkin argues, require leadership as “positive deviancy”. A positive deviant is:

 

“a person who does the right thing for sustainability, despite being surrounded by the wrong institutional structures, the wrong processes and stubbornly uncooperative people” (2010 p1).

 

There is an urgent need for healthcare professionals to address the sustainability of current politics, economics and social practices (Goodman 2011). The exact nature of that response is down to individuals. However, without some macro analysis we are in danger of leading ourselves into the dark. This then leads us to ask about out ethical responsibilities on a globalised world.

 

Nurses’ ethical responsibility in a globalised world?

 

Globalization results in large capital flows, labour movement and displacement and the increasing dominance of TransNational Corporations (TNCs) on economic, social and political life. The demise of state power for the public good and its alignment with finance capital (Harvey 2010, Crouch 2011) – results in its increasing withdrawal from public services in many European countries. The TNCs and ‘the markets’ are two voices guiding politics. The current Eurozone crisis illustrates how politicians have to create polices that the international financial institutions feel are acceptable to them.  Collier (2008) suggests that we have a bottom billion stuck in poverty, and the WHO acknowledges wide health inequalities. Even for the Rich, threats to survival are not domestic but global. Perspectives are changing from local to global, the ethics of healthcare thus need to be discussed in this context. The WHO’s Millennium Development Goals also set a global policy framework. There is thusa need for another voice to defend global public goods such as health.

 

Ethical practice (source Austin 2008):

 

Paul Ricoeur (1992) suggested that ethics are about “aiming at the good life”, and so if this is the case we ought to consider the good for all. If everyone has a right to the opportunity for a good life, what should the Nursing response be? 

 

Consider the codes of Ethics that govern nursing practice. Where are they and what do they say?

 

Professional ethics:

 

   http://www.icn.ch/about-icn/code-of-ethics-for-nurses/  International Council of Nurses. Code of Ethics for Nurses.

 

Acting Ethically as a nurse in a global community requires a need for transformative thinking and leadership as positive deviance. 

 

 

My frame of reference is that healthy lives depend on a healthy socio-economic and physical environment as outlined in the Social Determinants of Health approach (WHO 2008) which has as its outer layer in the model ‘general socioeconomic, cultural and environmental factors’, i.e. social and environmental structures. Thus, I largely agree with Peter Morrall (2009) who argues that patterns of illness and disease are largely determined by issues of social structure and increasingly physical environments. Social structures protect some while damning others to misery and poverty as evidenced in the inequalities in health literature. The affluent even in poor countries and difficult environmental conditions live in ‘safe’ enclaves where they can ensure clean water and a ready supply of food, even in famine stricken countries, money buys food. However, even the affluent will be affected by global changes in certain key environmental limits.

 

The key power relationships operating at present is the hegemonic stranglehold of advanced consumer capitalism in which the richest 2% own 50% of the world’s wealth (Davies et al 2006). Many do not understand or recognise the notions of limits, while others put undue faith on the resourcefulness of humanity to solve the problems but to do so within the frame of reference of ‘business as usual’ unaware that their selves are interconnected and interdependent within a much wider framework of meaning.

 

Thus there is a need to transform thinking. Currently leadership is the problem not the solution because we are not asking what we are leading for.

 

To encourage and transform leadership there is a need to engage in provocative pedagogy whereby we engage in intellectual critique through being challenged with provocative positions. We need a sociological imagination to connect personal troubles with public issues, to fully understand their personal biographies as related to wider social forces at this point in history.

 

Medical and nursing disciplines cannot be immune from this process. It is not enough to learn how the body works and what to do when it goes wrong. This is navel gazing of the worse kind. Many doctors and nurses have for a long time been pioneers for social action, acting on behalf of the poor, weak and vulnerable. That is their ethic. That has been their historic mission, the problems of this messy little world may not mean a hill of beans to many but without a reawakening of consciousness and a reconnection of self to others, which includes the biosphere, the future looks grim. Peter Morrall (2009) has argued that we as health professionals and/or academics have an ethical responsibility to take individual, collegiate, and organisational action with regard to the social ills which affect human health and happiness.

 

However, taking a stand is hard. Ethics is hard.Ethics requires thinking. We may be the only sentient being on the planet who can think and reflect on our existence and the search for ‘truth’  It may be that we have a special responsibility to think about our decisions and why we make them. Damon Horowitz has recently argued (2011):

 

Not only can we think,we must.Hannah Arendt said,“The sad truthis that most evil done in this worldis not done by peoplewho choose to be evil.It arises from not thinking.”That’s what she called the “banality of evil.”And the response to thatis that we demand the exercise of thinkingfrom every sane person

 

But this may lead to ‘Moral distress’ and Moral responsibility – by understanding the disparities in health if we have responsibility what does that mean? We may provoke moral distress, but then what?

 

 

Austin, W. Chapter 3 in Tschudin, V. and Davis, A. (eds) (2008) The Globalisation of Nursing. Radcliffe. Oxford.

 

British Medical Association (2008). ‘Health professionals taking action on climate change’, http://www.bma.org.uk/ap.nsf/Content/climatechange

 

British medical Association (2011). The health and security perspectives of climate change. October 17thhttp://climatechange.bmj.com/statement

 

Collier, P. (2008) The Bottom Billion, OUP. Oxford

 

Costello, A. et al  (2009). Managing the effects of Climate change. Available online at http://www.thelancet.com/climate-change

 

Crouch, C. (2011) The strange non death of neoliberalism. Polity Press

 

Davies, J.,  Sandstrom, S., Shorrocks, A., and Wolff, E. (2006) The world distribution of household wealth. December. UNU-WIDER http://www.wider.unu.edu/events/past-events/2006-events/en_GB/05-12-2006/

 

Economist, The. (2011). Left behind. September 10th. http://www.economist.com/node/21528614

 

Falk-Rafael, A. (2006) Globalization and Global Health: Toward Nursing Praxis in the Global Community. Advances in Nursing Science: January/March 2006  29 (1) p 2-14

 

Goodman B., Richardson J. Climate Change, Sustainability and Health in United Kingdom Higher Education: The Challenges for Nursing in: Jones P., Selby D., Sterling S (2009). Sustainability Education: Perspectives and Practice Across Higher Education. London, Earthscan.

 

Goodman, B. (2011). The need for a sustainability curriculum in nurse education. Nurse Education Today [online] http://www.nurseeducationtoday.com/article/S0260-6917(10)00262-5/abstract 14th January 2011

 

Harvey, D. (2010) The enigma of capital and the crises of capitalism.

 

Horowitz, D. (2011) Calls for a moral operating system. TED.com http://www.ted.com/talks/damon_horowitz.html?utm_source=newsletter_weekly_2011-06-07&utm_campaign=newsletter_weekly&utm_medium=email

 

 

Marmot, M. (2010) .Fair society, Healthy Lives. The Marmot Review. Strategic review of health inequalities in England post 2010. http://www.marmotreview.org

 

Morrall P (2009a). Sociology and Health. London: Routledge.

 

Parkin, S. (2010). The Positive deviant. Sustainability leadership in a perverse world. Earthscan . London.

 

Peccie, A. (1982). One Hundred Pages for the Future: Reflections of the President of the  Club of Rome. Futura books.

 

Ricoeur, P. (1992) in Austin (2008) op cit.

 

Tschudin, V. and Davis, A. (eds) (2008) The Globalisation of Nursing. Radcliffe. Oxford.

 

Wilkinson R and Pickett K (2009).  The Spirit level. Why equality is better for everyone. Penguin. London.

 

World Health Organisation (2008). Closing the gap in a generation. Health equity through action on the social determinants of health.  WHO.

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